94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB4086

 

Introduced 6/27/2005, by Rep. Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/15

    Amends the Managed Care Reform and Patient Rights Act. Requires health care plans to provide certain information on participating physicians to enrollees and prospective enrollees. Requires the removal of physicians who are deceased or are no longer practicing medicine from the list. Requires health care plans to provide periodic updates of physician listings with new and corrected information in printed form and on the plan's Internet website.


LRB094 12785 LJB 47629 b

 

 

A BILL FOR

 

HB4086 LRB094 12785 LJB 47629 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Managed Care Reform and Patient Rights Act
5 is amended by changing Section 15 as follows:
 
6     (215 ILCS 134/15)
7     Sec. 15. Provision of information.
8     (a) A health care plan shall provide annually to enrollees
9 and prospective enrollees, upon request, a complete list of
10 participating health care providers in the health care plan's
11 service area and a description of the following terms of
12 coverage:
13         (1) the service area;
14         (2) the covered benefits and services with all
15     exclusions, exceptions, and limitations;
16         (3) the pre-certification and other utilization review
17     procedures and requirements;
18         (4) a description of the process for the selection of a
19     primary care physician, any limitation on access to
20     specialists, and the plan's standing referral policy;
21         (5) the emergency coverage and benefits, including any
22     restrictions on emergency care services;
23         (6) the out-of-area coverage and benefits, if any;
24         (7) the enrollee's financial responsibility for
25     copayments, deductibles, premiums, and any other
26     out-of-pocket expenses;
27         (8) the provisions for continuity of treatment in the
28     event a health care provider's participation terminates
29     during the course of an enrollee's treatment by that
30     provider;
31         (9) the appeals process, forms, and time frames for
32     health care services appeals, complaints, and external

 

 

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1     independent reviews, administrative complaints, and
2     utilization review complaints, including a phone number to
3     call to receive more information from the health care plan
4     concerning the appeals process; and
5         (10) a statement of all basic health care services and
6     all specific benefits and services mandated to be provided
7     to enrollees by any State law or administrative rule.
8     In the event of an inconsistency between any separate
9 written disclosure statement and the enrollee contract or
10 certificate, the terms of the enrollee contract or certificate
11 shall control.
12     (b) Upon written request, a health care plan shall provide
13 to enrollees a description of the financial relationships
14 between the health care plan and any health care provider and,
15 if requested, the percentage of copayments, deductibles, and
16 total premiums spent on healthcare related expenses and the
17 percentage of copayments, deductibles, and total premiums
18 spent on other expenses, including administrative expenses,
19 except that no health care plan shall be required to disclose
20 specific provider reimbursement.
21     (c) A participating health care provider shall provide all
22 of the following, where applicable, to enrollees upon request:
23         (1) Information related to the health care provider's
24     educational background, experience, training, specialty,
25     and board certification, if applicable.
26         (2) The names of licensed facilities on the provider
27     panel where the health care provider presently has
28     privileges for the treatment, illness, or procedure that is
29     the subject of the request.
30         (3) Information regarding the health care provider's
31     participation in continuing education programs and
32     compliance with any licensure, certification, or
33     registration requirements, if applicable.
34     (d) A health care plan shall provide the information
35 required to be disclosed under this Act upon enrollment and
36 annually thereafter in a legible and understandable format. The

 

 

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1 Department shall promulgate rules to establish the format
2 based, to the extent practical, on the standards developed for
3 supplemental insurance coverage under Title XVIII of the
4 federal Social Security Act as a guide, so that a person can
5 compare the attributes of the various health care plans.
6     (e) The written disclosure requirements of this Section may
7 be met by disclosure to one enrollee in a household.
8     (f) As part of the list of participating health care
9 providers required to be provided to enrollees and prospective
10 enrollees under subsection (a) of this Section, a health care
11 plan shall provide current and accurate information on
12 participating physicians, which shall include, but not be
13 limited to, the specialty practice area of each participating
14 physician. Any participating physician who is deceased or is no
15 longer practicing medicine shall be removed from the list.
16     Health care plans shall provide periodic updates of
17 participating physician listings with new and corrected
18 information in both printed form and on the plan's Internet
19 website, if applicable.
20 (Source: P.A. 91-617, eff. 1-1-00.)